Welcome to the Patient Financial Navigator Foundation, Inc.

1. Welcome to the Patient Financial Navigator Foundation, Inc. PFNF Education 2017

2. A Community Outreach Program • The Patient Financial Navigator Foundation, Inc with its home base in Twin Falls, Idaho, is thrilled to present free educational programs for patients to attack the hassle factor in healthcare. Day Egusquiza, President, with over 37 years’ experience in healthcare including 20 years at an Idaho hospital, will guide the Patient Financial Navigator Foundation which will create a pathway for patients with multiple educational efforts – thru employers, payers, boot camps– while developing networks and a Resource Library to help navigate thru the maze called healthcare. Transforming healthcare one patient at a time. An advocate for all! • NO cost to the Employer for any employer programs. • NO cost to the community for any community programs. • NO cost to the community for the Boot camps • NO cost to the community for the Navigator Resource Library

3. Why create the Patient Financial Navigator Foundation, Inc? No one really understands their healthcare insurance until they need it. No one realizes the ‘next steps’ once the medical incident has occurred/been ordered. When a family is in a healthcare crisis, their life is disrupted, scared and vulnerable - coordination/communication is required to reduce the hassle factor. THE FOUNDATION IS AN INNOVATION LAB – finding new ways to transform today’s chaos. PFNF Education 2017

4. The Patient Challenges with HealthCare • No one ‘asks’ to come to a hospital. • Patient’s lives are impacted – they are scared, they feel out of control, they are lost with the overwhelming factors of cost/unknown, multiple providers, and continuing frustration with ‘who knows all of this?” • Patients are unaware of the many changes with their insurance, government programs, employer’s coverage and all the ‘rules’ associated with getting services paid. • Patients historically access hospitals once a year or less. Healthcare is very personal!

5. But Patients Don’t Speak the Language of Health Insurance Today…

6. …and They May Not Identify with the Language of Value-Based Care Tomorrow Source: M. Ross, T. Igus, and S. Gomez, “From Our Lips to Whose Ears? Consumer Reaction to Our Current Health Care Dialect.” The Permanente Journal. Winter 2009, Vol. 13, No. 1. http://www.thepermanentejournal.org/files/Winter2009/dialect.pdf

7. Additional ‘factors’ influencing the patient experience= confused=hassle factor • Electronic medical record /EHR – incentive and penalties • Integrated systems between providers/doctors and hospitals but safety with data sharing a concern. • Quality reporting systems –with rewards and penalties • Physicians new payment system- MACRA & MIP • Alternative payment systems for hospitals, doctors, long term care, DME , home health – all in the midst of rolling out with the goal of increased quality, reduced costs and more engaged patients. • What about a change to ‘privatizing’ Medicare? Voucher program -means?

8. Improve the experience Take the Hassle Out of the Experience Hassle Map: Elective Surgery for an Insured Patients- who knows to do this? Source: Based on the hassle-map construct developed by Slywotzky (2011).

9. What is the PFNF, Inc? • A not-for-profit Foundation with the focus on transforming …thru Education. Three legs of the Foundation’s Outreach Mission: • Community Outreach – Boot Camps • Employer Outreach – Lunch and Learn for employees • Navigator Resource Library- personal pt/family • As significant healthcare changes occur along with ongoing ‘healthcare buzz’ updates= Foundation! PFNF Education 2017

10. Three components of this dynamic program- A community outreach program

11. 1st) Example of Community Outreach Education – Boot Camps Identify community leaders to participate in the boot camp trainings Identify thru existing community services, additional healthcare related ‘hassle factor’ training. Provide education to high schools, colleges, regional and others as requested. Join with existing educational efforts – clinical in nature – to add the financial ‘translation’ for ease of understanding ‘what happens now.” Innovation lab – creating community specific ed.

12. Population Health means… • As we look to the transforming nature of healthcare – moving from sickness to wellness including quality/value based services with measurable outcomes vs volume/paid for all services with no quality outcomes required PLUS new commercial payer rules… • The Navigator Foundation is in the tent with a multi-disciplined/clinical approach to healthcare – Population Health – managing the chronic, social-economic determining factors, while remembering the pt didn’t ask to get sick, didn’t ask to have their life disrupted and didn’t ask their insurance to pay so little (high deductibles and co-payments) or no insurance at all. Triple Aim..1st=Pt engagement/empowerment. ‘Integration of clinical health and financial health for the holistic approach to population health.’ PFNF Education 2017

13. Trusted HealthCare Educator Participate: Office on Aging events Wellness Fairs Population Health dialogue/changes = ‘translator’ New transformations in healthcare Employer work place insurance initiatives Next generation of healthcare –with partners School outreach – high school, colleges As requested

14. Upcoming Community Outreach Boot Camps 2nd Boot Camp 2017 ‘Medicare 101, Social Security Benefits, and Assistance for Seniors. CSI 12:30-4:30 pm July 3rd Boot Camp 2017 “Turning 65 Boot Camp” CSI Oct 28th 8:30 -1:30 pm 4th Boot Camp 2017 “All Employer Insurance Boot Camp” 4th Q Commit up to 5 boot camps yearly. Additional potential topics: Population Health means……………. Transforming Health Care means……… Healthcare or Insurance Reform or what is changing in healthcare and how will it impact me?

15. Humana’s – Bold Goals programMajor % of market is Seniors- Part C Medicare* (HEALTHCARE BUZZ EX) • 65% of Seniors have multiple chronic conditions • 1/3 have diabetes • 1/4 have mental health • 10% live below the poverty level • 6 doctor visits yearly • 27 prescriptions yearly High cost to the healthcare system for ‘navigating thru’ alone. Social-economic issues. EX) Depressed? Not taking chronic meds. EX) Can’t afford meds = ED is next. (Medicaid?) *Population Health Colloquium. March 27, 2017 Philadelphia PFNF Education 2017

16. 2nd) Example of Employer-Specific “Lunch & Learn” Meet with the HR staff to learn about the employer’s insurance plan. Outline the key elements for education to be covered during the 30 min employee ‘Lunch and Learn.’ Hot spots for education (usually): EOB education, out of network, what happens when you are scheduled for a surgery and ‘HealthCare Buzz’ ++ Q&A. Innovation lab – taking the education to the employer.

17. Employment “Norms” in Huge Flux AARP & MIT Agelab(Population Health 3/17) • By 2020: 1 in 5 students will be 35 yrs or older. • By 2030: 10,000 will be turning 65 every day • By 2020: 1 out of every 5 adults will be over 65; more than under 5 yrs. • 57 year old's are the primary owner of IPad. • 50% of over 60 year old's use the internet • Over 50 years of age = 1/3 of the work force. • Family Care Giver: 42 M adults , age 45-64, providing care for older family/parents. 17%/ 24 M are providing in addition to their ‘day job.’ Multi-generations in the work force. Norm: 3-4 generations. (BB and Millennials = both approach ‘work’ differently.) WOW! A huge opportunity to create a new work place for diverse employee needs/retention. HealthExecMobile -Multiples • 18.4% of US adults had a mental illness in the past year. • 8.6% reported substance abuse/dependence in the past year • Almost 40% had at least one chronic medical condition during their lifetimes • 1.2% had all three conditions: mental illness, substance abuse/dependence and at least one chronic medical condition. AND more than 50% of Americans now have at least ONE chronic health condition, mental disorder or substance use issue. (Taylor & Francis group news – “Psychology, Health, and Medicine” Oct 2016.) Employees/Pts look different – ages (3-17) • Baby Boomers 51-69 74.9 M • Generation X 35-50 74.2 M – to Surpass BB by2028 • Millennials 18-24 75.4 M – HAVE surpassed BB

18. Health Care Buzz (Ex) 55% of Americans are paying more than last year for insurance. • 1 of 4 Americans health worsened after delaying care because of cost concerns • 30% said their health insurance coverage has gotten worse in the past year. • 1 in 4 lost access to their doctors last year due to insurance networks. (out of network huge costs!!) • 3 in 10 delayed emergency care in the last year out of fear of costs DailyFactoid / MCOL 10-16 Morning consult Biggest changes Doctor’s expect to result from Millennial patient habits in coming years. • Increased use of telemedicine (28%) • Proliferation of walk-in clinic settings (27%) • Growth in online scheduling and extended hrs (24%) • Greater transparency for out of pocket costs (11%) • Easily portable electronic health records (10%) Sprocket Rocket 12-6-16 “Millennial patients challenging status quo, over 2900 US doctors say.” PFNF Education 2017

19. Employer Insurance Costs/Changes Average Health Savings Account balance for 2015 = $1844 (Can have up to $3400/single; $6750/family) Average contribution by individuals = $1864 Average employer contributions =$948 Average high deductible plan: $2600-13,100 /family; $1300-6550 /single Benefit: Amt deferred for tax impact. Con: Family would have to pay premiums, deductible $, co-insurance $ AND have enough left to put money in the HSA. PS Did we mention impacts from the ACA/aka Obamacare? Healthcare spending 2015-16 • Spending averaged $5141 per individual. • Out of pocket rose 3% to aver $813 per capita • Prescription drugs increased 3.5-9% • Women of all ages spent $236 more out of pocket than men. • $649 per capita was spent on brand prescriptions. • The price of an ER visit jumped 10.5% to an aver of $1,863 • Employers contribute about 73% toward the monthly premium for individuals. 38% for dependents. *MCOL 3-17

20. So now you need healthcare – Outpt surgery (Sample) – in network • Surgeon’s office will contact your insurance carrier to get the surgery pre-authorized. Insurance carrier has their own criteria for medically necessary services. Many times requires ‘negotiation’ with provider and payer. • Routine bills for an outpt surgery- usually each sent separately: Surgeon Anesthesiologist Pre-op testing Procedure location (Hospital, free standing ctr) IMPORTANT: Validate all of the above are within the network that is part of Cigna’s plan. IN NETWORK

21. Let’s look at out of network- Surgery done at out of network hospital • Surgery done at an out of network hospital. • Billed charges: $8000 • Out of network deductible applied: $2000 individual • Hospital bills Cigna; Cigna pays ‘reasonable amt’ that would be paid to IN network providers. • Amt eligible for payment from Cigna: $4400 • LESS $2000 out of network deductible • LESS 50% out of network coinsurance after deductible: $2400 x 50% = $1200 • TOTAL AMT PD BY CIGNA: • $4400-$2000 ded- $1200 coins = $1200paid to out of network provider/hospital. • But the hospital is NOT contracted. Therefore, the hospital accepted the $4400 but left due on the account for the pt to pay: $8000 – $1200 = $6800 from pt. **Out of network deductible: $2000 (Separate from any in network deductible) **PLUS 50% copayment: $1200 **PLUS balance billing due to no contract: $8000 - $4400 =$3600 TOTAL DUE FROM PT: $6800

25. Think like a pt – out of network (means what to the pt or family?) • 40 year old has had emergency foot /ankle surgery approx 8 years ago and taken to a Boise hospital. The surgeon specialized in this type of foot surgery. Both in network at that time. • 3 surgeries later –still problems with rebuilding the foot to allow the pt to walk. • July 2013, employer changes plans and now the doctor and hospital who employees the doctor is out of network. • The pt continues to go to the surgeon who does another surgery Oct 2014 and a follow up minor surgery in 2015. Pt was aware of the change but did not know to do anything different as he was in continuing care. • Insurance pays significantly lower – no adjustment from charges as out of network/no contract. Pt pays all charges except actual payment to doctors, hospitals, tests. Huge financial hit. • What does the employee or pt know of the a) ramifications of out of network, b) prior notice to get approved and c) appeal rights?

26. 3rd) Examples from the Onsite Navigator Resource Library Thru employer specific meetings, build data base of insurance plans, how to read the EOB, deductibles, etc. 1 on 1 intervention with the patient/family – complete work paper Create glossary of terms Create reference guide for additional community resources Create networking ‘handoffs’ with existing hospital team - payment options, social work, estimates, patient experience, physician offices, others Innovation Lab: After Hours Q&A – Weds 5:00 -6:00 p.m.; using patient portal; tracking and trending improvements/feedback; integration with medical community; face to face and automation. Volunteer staffing plus a full time Manager and an unpaid Director/Foundation

27. Think like the family who is scared with a new ER visit w/insurance, employer specific • Daughter has just been admitted thru the ER. (Inpt vs obs means what to the pt?) • Parents are scared and distraught about the health of their daughter with the unplanned ‘admit.’ • As comforting as the care givers are, the financial questions loom large. What happens now? • Who has insurance? What was done with the insurance? What is my coverage? “I have never had to use it before, so I don’t know anything! “ • Think Pt Financial Navigator Program referral

28. Think like a patient – Medicare Part C/Managed Care – comes to the ER • 86 year old with Humana. What is done in the ER to inform the pt this is not traditional Medicare? • If the pt is ‘admitting/obs or inpt” – what happens so the pt understands the difference between Traditional Medicare and Part C/Mgd Medicare? • Now they are in a bed, what happens so the 86 year old understands their out of pocket, what coverage there is with Humana that may be different than Traditional, is this obs or inpt? Who has this information for our sick, confused Sr who does not have anyone to ask? • Care givers/family – who do they ask about the above? • Think Pt Financial Navigator Program referral

29. Included in Every Event/Training- “HealthCare Buzz” • Factoid: Health Exec Mobile Mon, March 27, 2017 “Although only 4% of all doctors are emergency physicians, they provide care for: 28% of all acute care visits 50% of all Medicaid and CHIP (children) visits 67% of all acute care to the uninsured patients. • Healthcare Bulletin. The Slate Group. March 30, 2017 “An annual health survey conducted by states and Medicare/CMS found that the full ACA reduced the uninsured rate by 44% while also reducing the number of people without a primary care doctor by 12% and those not having an annual check up by 10%.”

30. What about Accountable Care/ObamaCare? Brief history Using Families USA website – a 50-state look at Medicaid Expansion 2016. • 32 states expanded, 19 did not. (Idaho did not) “The poorest of the poor” • Fed govt covers 100% of cost at the state’s Medicaid /lower rate thru 2016. Then 90% • Covered lives at risk of losing coverage: 8.2 mil (6.2 m in the 19 non-expanded states) • Idaho stat: A 3 person family can’t make more than $5,424 a year in income. A single parent with 2 kids working a full time job at minimum job makes too little to help buy private insurance but too much for Medicaid because Idaho did not expand Medicaid. • Potential for new covered lives if expanded for Idaho: 90,000. Health Industry in panic over threatened Obamacare repeal and Obamacare signups skyrocket after election • With the growth/since the election in the enrollment period, the total covered under the Exchange Program is approx. 20 mil. This includes subsidies for lower income. (MSN 11/23/16) • Plus Employed Mandated Plans (50+ mostly) (As of end of 2016) PFNF Education 2017

31. Compare Accountable Health Care/ACA vs American Health Care Act-highlights ACA AHCA No mandate No mandate for employers Discussion on lifting requirement for coverage – maternity, birth control and mental health Exchange still in play but no requirement to have insurance. Allow the ‘market’ to determine coverage options. Tax credit based on age. $2000/single. No subsidies Pre-existing unless a break in coverage (think job loss or change). Then 30% higher premiums Excellent article: “Rural Hospitals may see largest impacts under healthcare overhaul.” Rich Daly, HFMA Senior Writer 3-17-17 • Individual Mandate – everyone has insurance • Employers 50+ must offer insurance with essential benefits • Exchange insurance market place unstable. Used for self employed, unemployed, under 50 employees, students if not covered under parents or thru the college plan • Insurance plans had to ‘donate’ to help cover subsidies for low income. • Premiums are controlled by insurance plan. Risk sharing –healthy and sick = premium range rate • Pre-existing protection Excellent articles: “Insured thru your job? Medicaid? The ACA? Here’s what could change>” Consumer reports, 3-13-17

32. It is all doable.. • Have the vision and the passion to make a difference in the hassle factor in healthcare • Remember – all the automation does not replace the human touch. • Remember – our families are the core of healthcare. • It is very personal! Thanks, Day Egusquiza Founder/President Webpage: Http://PFNFInc.com Like us on Facebook.com/PFNFInc